Patient Medical History

Date:

Patient Name:

First Name


Last Name

Birth Date:

Are you under a physician's care now?


If Yes:

Have you ever been hospitalized or had a major operation?


If Yes:

Have you ever had a serious head/neck injury?


If Yes:

Are you taking any medications, pills, or drugs?


If Yes:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?


If Yes:

Are you on a special diet?

Do you use tobacco?


Women: Are you...

Are you allergic to any of the following?

Asprin, Metal, Penicillin, Latex, Codeine, Sulfa Drugs, Acrylic, Local Anesthetics, Other? None?

If Yes:

Do you use controlled substances?


If Yes:


Do you have, or have you had, any of the following?

AIDS/HIV Positive, Alzheimer's Disease, Anaphylaxi, Anemia, Angina, Arthritis, Artificial Heart Valve, Artificial Joint, Asthma, Blood Disease, Blood Transfusion, Breathing Problems ,Bruise Easily, Cancer, Chemotherapy, Chest Pains, Cold Sores/Fever Blisters, Convulsions, Cortisone Medicine, Diabetes, Drug Addiction, Easily Winded, Emphysema,Epilepsy/Seizures, Excessive Bleeding, Excessive Thirst, Fainting.Dizziness, Frequent Cough, Frequent Diarrhea ,Frequent Headaches, Genital Herpes, Glaucoma, Hay Fever, Heart Attack/Failure, Heart Murmur, Heart Pacemaker, Heart Trouble/Disease, Hemophilia, Hepatitis A, Hepatitis B or C,Herpes, High Blood Pressure, High Cholesterol, Hives or Rash, Hypoglycemia, Irregular Heartbeat, Kidney Problems, Leukemia, Liver Disease, Low Blood Pressure ,Lung Disease, Mitral Valve Prolapse, Osteoporosis, Pain in Jaw Joints, Parathyroid Disease, Psychiatric Care, Radiation Treatments, Recent Weight Loss, Renal Dialysis, Rheumatic Fever, Rheumatism, Scarlet Fever, Shingles, Sickle Cell Disease, Sinus Trouble, Spina Bifda, Stomach/Intestinal Disease, Stroke, Swelling of Limbs, Thyroid Disease, Tonsillitis, Tuberculosis, Tumors or Growths, Ulcers, Venereal Disease, Yellow Jaundice
If Yes:

Have you ever had a serious illness not listed?


If Yes:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, or Guardian

First Name:

Last Name:

Date: